HomeMy WebLinkAboutMiscellaneous - 337 SUMMER STREET 4/30/2018 (2)ljF?. r�r is
IT
.
North Andover Board of Assessors Public Access
Parcel ID: 2101107.A-0173-0000.0
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Community: North Andover
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Location: 337 SUMMER STREET
Owner Name: BISSELL FAMILY REALTY TRUST
J F H& S J BISSELL, TRS
Owner Address: 337 SUMMER STREET
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 6 - 6 Land Area: 1 acres
Use Code: 101- SNGL-FAM-RES Total Finished Area: 3302 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 662,400 620,400
Building Value: 452,400 426,100
Land Value. 210,000 194,300
Market Land Value: 210,000
Chapter Land Value:
LATESTSALE
Sale Price: 1 Sale Date: 02/08/1998
Arms Length Sale Code: F-NO-CONVNIENT Grantor: JOSEPH BISSELL
Cert Doc: Book: 04959 Page: 0047
Page 1 of 1
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=809389 8/14/2006
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 7/14/16
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -box and outlet tee
By: Todd Bateson
At:
337 Summer Street
Map 107.A Lot 0173
Nth Andover, MA 01845
of this erti�td shall not be construed as a guarantee that the system will function satisfactorily.
�i � n g Y Y
Michele Grant
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
North Andover Health Department
(ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 337 Summer St.
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
MAP: 107.A , LOT: 0173
INSPECTIONS
D -box and outlet tee INSPECTION: 111411cp
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
Comments:
(gas baffle/effluent filter)
❑
inch cover to within 6" of finish grade
installed over one access port
❑
Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑
Bottom of tank hole has 6" stone base
❑
Weep hole plugged
❑
1500 gallon Pump Chamber installed
❑
H-10 loading
❑
Monolithic tank construction
❑
Inlet tee installed, centered under access port
❑
Pump(s) installed on stable base
❑
Alarm float working
❑
Pump On/Off floats working
❑
Separate on/off floats
❑
Drain hole in pressure line
❑
cover at final grade installed over pump
access port
❑
Water tightness of tank has been achieved by
testing
❑
Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
❑
Alarm & Pump are on separate circuits
❑
Alarm sounds when float is tripped
❑
Location of control panel: basement
❑
Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX
Installed on stable stone base
H-20 D -Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Schedule 40 PVC Pipe
Comments:
Commonwealth of Massachusetts Map -Block -Lot
107.A0173
BOARD OF HEALTH -----------------------
Permit No
North Andover - BHP -2016-0226 - ---------------------
FEE
$175.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
to (Repair) an Individual Sewage Disposal System.
at No STREET
------337-----SUMMER-----------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2 Dated July 11, 2016
FILECOPY-------------------------------------------------- ----
On: Jul -11-2016 BOARD OF HEALTH
1'
•Mull
Important
When`filliing out
forms on the
computer, use
only;the tab key
to:move your
cursor --do not
use the return
key.
Al ppJi -ation #or eptic disposal .Syster
Construction Permit- TOWN OF
NORTH ANDOVER,: MA 01845
TODAY'S DATE
❑ Repair or replace an existing. on-site sewage disposal' system*
2'kepair or replace an existing system component —What? --,P-v u v wtt C cT 1 -cam_
A. Facility Information
3 3 7
Address or Lot #
�ff[ .E1!/ C
Cityfrown JUL .I 12016
2: *TYPE OF SEP IC SYSTEM%
➢ ❑ Pump Gravity (choose one) 'OWN OF NORTH ANDOVER
***If pump system, attach copy of electrical permit to application'** HEALTH DEPARTMENT
➢ ❑ Conventional System (pipe and stone system)
➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
❑ Pressure Distribution S.A.S. (No D -Box)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES = (no further info. needed)
'NO = (installer must specify brand of filter before DWC issuance)
What is the Make?
2. Owner Information
What is the modal
Name 1
Address (if different from above)
City/Town State Zip Code
sno
Telephone Number
3. Installer Information
Name Name of
Address
/'tom •f ",� "
Cityfrown
4. Desi.gnerinforrnation
Name
Address
City/Town
M
111 ARGILLA ROAD
WDOVER, MA 01810
State Zip Code
9 � 9'Is- n 7,o3
Telephone Number (Cell Phone # if possible. please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
0
4 -7/4 .
TODAY'S DATE .
$:250.00 T Full Repair
$'125.00 - Component
PAGE 2 OF 2
A. Facility. Information continued....
S. Type* of BuAdina: esidentialDwelling or (]commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage dlsposal system In accordance with the Prov/slons of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system In operation until a Certlf/cate of Compliance has
been lssu4q this Board of Heath.
Name Date
A o rd. d By: (Board of Health Representative)
<< (0
Pate
e Date
Application Disapproved, for the following reasons:
For Office Use OMY: ; ..
1
Fee Attached?:
Yes
No
2.-
ProjectMattager Obligation Form Attached.
Yes
No '
3.:
Pu�mn SestemP Ifsoi Attach cony ofElecttreal B=—&:.:
•;
No
4.
Fouadat 0,a As Built.? (new construction •ronly):
Yes
(Same scale as approyedplan)
No
_
A
FloorPLws? (new coiistructlon- only):
des
J'
No
Appifcatfdn dor p�sppsal. ysterit:tronstfncfiori Permft � Rage 2 of 2
•SEP'�IC SY3�'I�12•IN�"3'�!�•�Rd,'!'.i�iA�►�E;1�I��•�p8%iGA�'It}i1TS
As flie.Nwth Andover lowed bitsou fru 4Qie:t�"atmcft for• ;BVdc orteMI'at &cVopetty at:
.,,,('
t� etas) .-Fbt pim by ...�—�..�..�
Rostime to ditappotim of "�% 1i 4 /„P 5iw '
ffis s conte Abd dobd
-\T'
Dated
s W t MWOM dated
• {I,asc aed d�tej
I uatle>latand the following obligations foo s sagement G lds project:
1. As the iatW* I s'm.oblig W iv-
obt da affpemx'b and'BowA of �esd& rtppsoved pkmft o0
�et5onming afly:work oa a site. I niQat have tits �arav� ��dw
LID
2. At die .I. Il suty and eR Via: 'Ehmawnek=ftcbcK pzgectman%,e4 oc any
*Owpamon notmmodwdwith my co" bgkm#m and dw,,sis notnady, titch
item 6sea•aba bi li�tble. '
�; tp lzxvc a ate y c :ppid.to thcAnHcs*
_ 1 .... - �a aeaoi
. •� •,�::,.�,s }a���k.�l`6�'-;t�etc is tr ' ' r �iiclr
altsytd• t k!ntea nett to 4p
i>xsaut. - -
o OIfi (cs ems[ t. ctc.. .
ba itibiriitt,ed m ate-Boaad of Hates, sit; fo�•s6 � t oe. `I st
sidp ; l deetdattq qt be remly and Awe to
camp io
B ` ft*ffw tanatSogta "tbn *IVftg s r p ; iblisr does not
• hava #o berme. - •� � •• :. .
4. hs -*e msmlie;'I ted thatonly I~t�scpgt t fi t' ► s� I
m exg.111.1ete tlie} of tiAe syadtgtifrt atzi rimed
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,t: Detlaatfomtt.prsvperrtdara a�ftlre tgrr beep s+e,rc�eat
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oQmp�acatl� .. -
6.
UnderWpd' bomaSeptic.ftMU=
�.p� Ike.
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
Commonwealth of Massachusetts
Title 5 Official Inspection Form "tc
Subsurface Sewage Disposal System Form - Not for Voluntary Assessm' ZO
337 Summer Street rpt, OP 25 BOJ
Property Address
John Reddin ton (lyD%15, q OVlt-,
Owner's Name+T
North Andover MA 01845 7/14/2016
Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information,
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
Cityrrown
978-475-4786
Telephone Number
B. Certification
MA
State
S115
License Number
01810
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ N eds Fu
er Evaluation by the Local Approving Authority
7/14/2016
Insp o Signaturki Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3113 Title 5 Official Inspection Fort: Subsurface Sewage Disposal System • Page 1 of 17
- ' Commonwealth of Massachusetts
Owner
information is
required for
every page.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner's Name
North Andover MA 01845 7/14/2016
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from B.O.H., install new outlet tee with gas baffle, new d -box with riser, & inspection from
B.O.H. , septic system now passes Title 5 Inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 2 of 17
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
VQ
Commonwealth of Massachusetts RECEIVED
Title 5 Official Inspection Form JUN 13
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2016
337 Summer Street TOWN OF NORTH ANDOVER
uCAl TW r)PPAPTUPKIT
Property Address in/� 2<
John Reddington V11 J
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
5/31/2016
Date of Inspection
•inspect,ionresultsest�be-submWedvin Obisfou.4nspeciionfomes y•notdieabed4n-any
way. Please see completeness checklist at the end of tho form
A. General Information
Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
M/
City/Town
Ste
978-475-4786
SI
Telephone Number
Lic
B. Certification
N'lZe h I o r&�IkQ
C,/Jj
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑Ned Further Evaluation by the Local Approving Authority
r
5/31/2016
Ins of r' ignatu Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
reporttolha apptopriate'regiorial'olflce-oflhe'DEP. The original'should,be'senaotolhe-system,owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
v l�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
RECEIVED
JUN 13 2016
TOWN OF NORTH ANDOVER
HEALTH QFFRARTMENIT
Al -;kql
5/31/2016
Date of Inspection
,Inspection -results must be -submitted on 4hiis forrfh 4nspection fonvis may •not,be -altered 4n -any
way. Please see completeness checklist at the end of the form.
A. General Information
Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
MA
State
S115
License Number
01810
Zip Code
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑Ned Further Evaluation by the Local Approving Authority
5/31/2016
Ins ct r' ignatu Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report-toYhe'dpproptiate'regional'offlee'offthe1 P. The'ortgirial -should -be -sent to theWslem,owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 17
., Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 337 Summer Street
Property Address
John Reddington
Owner owner's Name
information is
required for every North Andover MA 01845 5/31/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
❑ .I have not found any information which indicates that any of the failure criteria described
in 310 CMS# !x.303 or in 3TC A 11.834 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Fieai(h.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ® N ❑ ND (Explain below):
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner owner's Name
information is
required for every North Andover MA 01845 5/31/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipes) or due to a'broken, settled or uneven distribution'box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is'removed
❑ Y ® N ❑ ND (Explain below):
❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will.pass inspection if {with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ® N ❑ ND (Explain below):
❑ Y ® N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR
1-5.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 3 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner's Name
North Andover
City/Town
B. Certification (cont.)
MA 01845
State Zip Code
5/31/2016
Date of Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
14W0 feet�of�a�surfaoewateriupply,or�trrbutary•to•a-eurfac : water -supply;
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
•fnore=from,a,private watersupply wall**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
°to,or4ess-than -5,ppm, provided-that•no•otherfailure-criteria°are°triggered.A•copy°oflthe:analysis•must
be attached to this form.
3. Other.
Pumed septic tank, replace d -box & outlet tee in septic tank.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System •Page 4 of 17
wpm
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner
information is
Owner's Name
required for every
North Andover
MA 01845 5/31/2016
page.
City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
❑
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑
® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑
® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no otherlailure criteria are triggered. A copy of `the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10, 000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
°criteria•existma described in 31,0,CMR 15.303, therefore the system faits. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ' ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3/13 1
Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' t 337 Summer Street
Property Address
John Reddington
Owner Owner's Name
information is
required for every North Andover MA 01845 5/31/2016
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following
Yes No
® ❑
Pumping information was provided by the owner, occupant, or Board of Health
❑ ®
Were any of the system components pumped out in the previous two weeks?
® ❑
Has the system received normal flows in the previous two week period?
❑ ®
Have large volumes of water been introduced to the system recently or as part of
this,lfi$Iect on?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 6 of 17
=is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner Owner's Name
information is
required for every North Andover MA 01845 5/31/2016
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
`intormatiion'in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available {last 2 years usage (gpd)).
Detail:
'Stam utnp
Last date of occupancy:
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
1)
®
Yes ❑
No
El
Yes: 0
No
❑
Yes ❑
No
❑
Yes ®
No
Yes
0 YJ&S_ ❑ No
Current
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner Owner's Name
information is North Andover
required for every
page. City/Town
D. System Information (cont.)
Last date of.occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01845
State Zip Code
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
Pumped 2008, owner
gallons
5/31/2016
Date of Inspection
❑ Yes ® No
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 337 Summer Street
Property Address
John Reddington
Owner owner's Name
information is
required for every North Andover MA 01845
page. Cityrrown State Zip Code
D. System Information (cont.)
5/31/2016
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
Original. owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" Cast Iron through wall, 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
If tank is metal, list age:
1
feet
El fiberglass ❑ polyethylene ❑ other (explain)
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10' x 5'x 4'
Sludge depth:
6"
❑ Yes ❑ No
t5ins • 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner Owner's Name
information is
required for every North Andover MA 01845 5/31/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee badly corroded, needs to be replaced.. Depth of liquid at outlet invert. No
evidence of leakage. Center cover has riser to grade.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner Owner's Name
information is
required for every North Andover MA 01845 5/31/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
❑ fiberglass ❑ polyethylene ❑ other (explain):
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner Owner's Name
information is
required for every North Andover MA 01845 5/31/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert -1/2"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence, of :Ieakage,into. r�r -aut of;box;
D -box badly corroded, needs to be replaced. Evidence of leakage, liquid
below outlet inverts 1/2". Evidence of carryover.
Pump Chamber (locate on site plan):
Pumps in working order:
❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
❑ Yes ❑ No
5ns • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
Form
Subsurface Sewage Disposal System Form - Not for Voluntary
Assessments
337 Summer Street
Property Address;
John Reddington
Owner
owners Name
information is
required for every
North Andover MA
01845 5/31/2016
page.
City/Town State
Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
❑ leaching trenches
number, length:
® leaching fields
1 field 20' x 60'
number, dimensions:
❑ overflow cesspool
number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
❑ Yes ❑ No
5ns • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner owner's Name
information is
required for every North Andover MA 01845 5/31/2016
page. City/Town . State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
ens • 3/13
Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner's Name
North Andover MA 01845 5/31/2016
City/Town State Zip Code
D. System Information (cont.)
Date of Inspection
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand -sketch in the area below
❑ drawing attached separately
t5ins • 3/13 Title 5 Official inspection Form: Subsurface Sewage Disposal System •Page 15 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington '
owner's Name
North Andover MA 01845 5/31/2016
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
Z Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 5/7/1977
tate
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Design plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
John Reddington
Owner Owner's Name
information is North Andover MA 01845 5/31/2016
ry
required for eve
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated on 5/19/2016 12:49:11 PM by Karen Hanlon
Town of North Andover
Tax Map # 210-107.A-0173-0000.0
Parcel Id 17999
337 SUMMER STREET
JOHN REDDINGTON
ANNE LANG
337 SUMMER STREET
NORTH ANDOVER, MA 01845
Page 1
Class 101 Single Family
Property Type
1 Residential
Zoning2 1 Residential
Zoning3
1 Residential
Size Total 1 Acres
FY 2016
UB Mailing Index
Name/Address
Type Loan Number
Active/Inact.
From
Until
JOHN REDDINGTON
Owner
ANNE LANG
337 SUMMER STREET
NORTH ANDOVER, MA 01845
BISSEL, JOSEPH
Previous Customer
Inactive
10/27/2006
337 SUMMER STREET
N. ANDOVER, MA
01845
DAVID PALMER
Previous Customer
Inactive
7/31/2008
337 SUMMER STREET
NORTH ANDOVER, MA 01845
UB Account Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 14268.0 - 337 SUMMER STREET Last Billing Date 3/14/2016
2100264
02 Cycle 02
Active
UB Services Maint.
Account No. 2100264
Service Code
Rate Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8 7.82
1/
WTR WATER
01 ALL METER SIZE 49.40
/1
UB Meter Maintenance
Account No. 2100264
Serial No Status
Location Brand
Type
Size
YTD Cons
33605551 a Active
ERT HH b Badger
w Water
0.63 0.63
907
Date
Reading
Code Consumption
Posted Date
Variance
5/4/2016
1232
a Actual
11
-15%
2/2/2016
1221
a Actual
13
3/28/2016
-69%
11/2/2015
1208
aActual
41
12/30/2015
12%
8/5/2015
1167
a Actual
38
9/14/2015
189%
5/5/2015
1129
a Actual
13
6/22/2015
-6%
2/3/2015
1116
a Actual
14
3/20/2015
-40%
11/3/2014
1102
aActual
23
12/15/2014
35%
8/4/2014
1079
aActual
17
9/11/2014
68%
5/5/2014
1062
a Actual
10
6/12/2014
-18%
2/4/2014
1052
a Actual
13
3/17/2014
-75%
10/31/2013
1039
a Actual
49
12/20/2013
71%
8/2/2013
990
a Actual
28
9/18/2013
133%
5/6/2013
962
a Actual
12
6/18/2013
14%
2/7/2013
950
a Actual
12
3/13/2013
-65%
10/30/2012
938
a Actual
30
12/13/2012
-21%
8/3/2012
908
a Actual
40
9/26/2012
311%
5/2/2012
868
a Actual
9
6/20/2012
-8%
2/6/2012
859
a Actual
11
3/14/2012
-72%
11/1/2011
848
aActual
37
12/15/2011
-28%
8/2/2011
811
a Actual .52
9/14/2011
347%
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
Commonwealth'& W14assachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Asses;
337 Summer Street
/T'4
7 K
RECEIVED -�
MAY 20 � 08 ®` t�-¢ss
�y`o�
TOWN ER
HEALTH DEANDOVER
Property Address
Carol Palmer
Owner's Name
No. Andover MA 01845 5/9/08
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
1. Inspector:
Benjamin C. Osgood, Jr.
Name of Inspector
New England Engineering Services, Inc.
Company Name
1600 Osgood Street Suite 2-64
Company Address
No. Andover
City/Town
978-686-1768
Telephone Number
B. Certification
MA
State
License Number
01845
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
[✓Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
'9� C 2
Inspect s Signature
g_Cgs
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 15
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner Owner's Name
information is
required for No. Andover MA 01845 5/9/08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
P I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner's Name
No. Andover MA 01845 5/9/08
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
TITLE 5 FORM MASTER.DOC • 08/06 - Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner's Name
No. Andover MA 01845 5/9/08
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well'".
Method used to determine distance:
** This system passes if the well water analysis, performedat a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
❑
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
❑—
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
ET—
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
ElRequired
pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
[�"-
Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
0—
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
TITLE 5 FORM MASTER.DOC • 08106
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner's Name
No. Andover MA 01845 5/9/08
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ Er Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ M,"' Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Er- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ 0' The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ [vThe system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes
No
❑
[�
the system is within 400 feet of a surface drinking water supply
❑
[3—
the system is within 200 feet of a tributary to a surface drinking water supply
❑
Eg,,-
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15
i;
M 5vvy`•
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner's Name
No. Andover MA 01845 5/9/08
Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Q' . ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ [' Were any of the system components pumped out in the previous two weeks?
X ■
AW11111111111 I✓
411111111100
n ■
IMEM-01
L
no
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
TITLE 5 FORM MASTER.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner Owner's Name
information is
required for No. Andover MA 01845 5/9/08
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): —— Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Last date of occupancy/use:
Other (describe):
6.00 GPD
[Yes ❑ No
❑ Yes Ea -No
❑ Yes R No
❑ Yes [9—No
63 GPC>
iu00 2007 lb Fsg D Q
2--y-es ❑ No
%'-CV!:!nT
Date
Gallons per day (gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Date
TITLE 5 FORM MASTER.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15
Commonwealth of Massachusetts
a v W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner Owner's Name
information is
required for No. Andover MA 01845 5/9/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Z 0c, (=e/ , aw VLF- ip—
gallons
❑ Yes (& No
Type of System:
[� Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
Approximate age of all components, date installed (if known) and source of information:
�O t.1Pr�(2c .0I'D &UL LT
Were sewage odors detected when arriving at the site? ❑ Yes e No
TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner's Name
No. Andover MA 01845 5/9/08
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
Zy ri
feet
7 cast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: y
feetJ
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
e( concrete ❑ metal
Z if
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
1,6-oo CsALcg,uS
L�
3y
M
a
6"
/t4aJ2E sTic4
TITLE 5 FORM MASTER.DOC • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner Owner's Name
information is
required for No. Andover MA 01845 5/9/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): /
TAIA1I1, iN is'COT> Coiw0 6"n0 ce-Ace, e4c }GGS I
Co Gln t?,GcowmG.� iws} � cMC) 421-- ittsPW 'fZ� w. (A r
o;F &2A -Dig. O ti
A -')A Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
A I.l. OPEN tAj (rS
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N 14 Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�•''� 337 Summer Street
Property Address
Carol Palmer
Owner Owner's Name
information is
required for No. Andover MA 01845 5/9/08
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert a
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
ROx fru &Tn6n C0PD.1a11 129.37-2if gu'7on F-&AjAi— ivO
x✓,.Pe-4cr DF gal'ltpS c&,261z Lx' 14A'&JF IAJ 6/Z
OV -171
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order.:
❑ Yes ❑ No
❑ Yes ❑ No
TITLE 5 FORM MASTER.DOC • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 115
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner's Name
No. Andover
City/Town .
D. System Information (cont.)
MA 01845 5/9/08
State Zip Code Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
#}-2E Ifi• n SdS
Type:
❑
leaching pits
❑
leaching chambers
❑
leaching galleries
❑
leaching trenches
R
leaching fields
❑
overflow cesspool
❑
innovative/alternative system
Type/name of technology:
number:
number:
number:
number, length:
number, dimensions:
number:
-/ E'er
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
MLCA' 0f` �l��r� L.0o ►cit /Vo/z.-A 4L. iyo FL.), O Plc e VF
RdND(A)A .�14AAP SL), L, 0J2 VA),ASJ4L UG&E�1�7_7DN.
TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 12 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,
337 Summer Street
Property Address
Carol Palmer
Owner's Name.
No. Andover MA 01845 5/9/08
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15
,o-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner Owner's Name
information is
required for No. Andover MA 01845 5/9/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
✓vMµER ST
P t<--rt-ANc.ES
L—T
qjs
2 —T
14.0
t - P5
q -7-E)
?-D$
Z3.s
M
TITLE 5 FORM MASTER.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
337 Summer Street
Property Address
Carol Palmer
Owner's Name
No. Andover MA 01845 5/9/08
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑
Check Slope
❑
Surface water
❑
Check cellar
❑
Shallow wells
Estimated depth to ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
I
Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
8 A -C -I M Fnr J>a-, A•NQ 6 ' a �c w G -2A-0 F. U G -s
N�A•PS .�D ICA -77 wIqM2 > Ce -d i3Ctow CSL V+0
TITLE 5 FORM MASTER.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15
{ 1 '
NEW ENGLAND ENGINEERING SERVICES, INC.
1600 Osgood Street Bldg 20 Suite 2-64
North Andover, MA 01845
Tel: 978-686-1768
Far: 978-327-6138
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
RECEIVED
AUG 1 1 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
July 26, 2006
RE: TITLE V REPORT: 337 Summer Street North Andover, MA
Dear Ms. Sawyer:
Enclosed is the Title 5 Report for the above referenced property. The system PASSES
the inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely,
i_C�
Benjamin C. Osgoo r.
Certified Title 5 Inspector
I 'Of 11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
337 Summer Street No. Andover, MA 01845
Owner's Name:
Joseph Bissell
Owner's Address:
337 Summer Street No. Andover, MA 01845
Date of Inspection:
July 20, 2006
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 1600 Osgood Street Building 20 Suite 2.64, North Andover, MA 01845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (3 10 CMR 15.000). The system:
_Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: i
7/2-o/O
The system inspection shall submit a copy of this msp&tion report to the Approving Authority ( Board of Health or DEP) within 30
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and
the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system
owner and copies sent to the buyer, if applicable, and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does
not address how the system will perform in the future under the same or different conditions of use.
2'6f 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
337 Summer Street No. Andover, MA 01845
Owner's Name:
Joseph Bissell
Date of Inspection:
July 20, 2006
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
�F S I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR
15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B System Conditionally Passes:
IV 0 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,
upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a
complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the
tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if
(with approval of the Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
ND explain.
3'of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
337 Summer Street No. Andover, MA 01845
Owner's Name:
Joseph Bissell
Date of Inspection:
July 20, 2006
C. Further Evaluation is Required by the Board of Health:
IVO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect
public health, safety or the environment
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is
not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and (SAS) Soil Absorption System and the (SAS) and the SAS is within 100
feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well**. Method used to determine distance
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organize compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered A copy of the analysis must be attached to this form.
3. Other:
t �
4'6f 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner's Name:
Date of Inspection:
337 Summer Street No. Andover, MA 01845
Joseph Bissell
July 20, 2006
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or
cesspool.
Y Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool
—y— Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/s day flow
'Y- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times
pumped
Yc Any Portion of the SAS, cesspool or privy is below high ground water elevation.
i< Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
t Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.)
6" L) (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR
15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to
correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
The system is 400 fat of a surface drinking Ovate ly
The system is within 200 fat tribu a surface drinking water supply
The system is located in a ' gen sensitiv (Interim Wellhead Protection Area — IWPA) or a mapped Zone II
of a public water well
If you answered "yes" y question in Section E the system is considered a si t threat, or answered "yes" in Section D above
the large syste s failed. The owner or operator of any large system considered a si t threat under Section E or failed under
Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner d contact the appropriate regional
office of the Department.
5411
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
337 Summer Street No. Andover, MA 01845
Owner's Name:
Joseph Bissell
Date of Inspection:
July 20, 2006
Check if the following have been done. You must indicate "Yes" or "no" as to each of the follow*ng•
Yes No
✓ Pumping information was provided by the owner, occupant, or Board of Health
✓ Were any of the system components pumped out in the previous two weeks_?
✓ Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of an inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
✓f Was the facility or dwelling inspected for signs of sewage back up ?
_V11, Was the site inspected for sign of break out?
VWere all system components, excluding the SAS, located on site?
_v1_ _ Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner ( and occupants if difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
_jG" Existing information. For example, a plan at the Board of Health.
. f::f- Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [3 10 CMR 15.302(3)(b)]
6411
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
337 Summer Street No. Andover, MA 01845
Owner's Name:
Joseph Bissell
Date of Inspection:
July 20, 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design)_ Number of bedrooms (actual): y
DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms) ( oma C1
Number of current residents:_
Does residence have a garbage grinder (yes or no): '� E 5
Is laundry on a separate sewage system (yes or no):AV) [if yes separate inspection required]
Laundry system inspected ( yes or no): r -
Seasonal use: (yes or no): A10
Water meter readings, if available (last 2 years usage (gpd): 14 37 Cr.P D t„asT 12_ r -A 0,.-E'� g
Sump Pump (yes or no):_ No
Last date of occupancy L�—r
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR. 15.203): gpd
Basis of design flow (seats/persons/sgk etc
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no)
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information:_ EAL L_ 7,00,5-
Was
oo5"Was system pumped as part of the inspection (yes or no):_ /V 0_
If yes, volume pumped: eallons — How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_ Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from
system owner)
Tight tank Attached a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected wen arriving at the site (yes or no): A/ 0
T6f 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 337 Summer Street No. Andover, MA 01845
Owner's Name: Joseph Bissell
Date of Inspection: July 20, 2006
BUILDING SEWER (locate on site plan)
Depth below grade: ;Z V
Materials of construction: V cast iron, 40 PVC„_other (e lain)
Distance from private water supply well or suction line: iv A.
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade:/ 2 � `
Material of construction: concrete metal fiberglass polyethylene
Other (explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate)
Dimensions: /,y''oo G,Q
Sludge depth:. G 1
Distance from top of sludge to bottom of outlet tee or baffle: _. ✓ b
Scum thickness: Z, l
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffled
How were dimensions determined:_ /0 Fj*rLj 12 G -
sic /G
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
Ti4N K t N Goad La j.jz? 4-00AJ, IFT,— 25-43 !/,j Cs-�d0
GdNS7 r??aN� 2EG-Cw t e—.c> ( Ajs 7�,41,k--7r%,-I e F:= /Z.1 S Ci%,r %'"Ico
oF� Lam- c5.� �c o��F.v��✓GS
GREASE TRAP:(locate on site plan)
Depth below grade:
Materials of construction: concrete metal fiberglass polyethylene other
(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of sludge to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.
8 bf 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 337 Summer Street No. Andover, MA 01845
Owner's Name: Joseph Bissell
Date of Inspection: July 20, 2006
TIGHT OR HOLDING TANK: A✓ l+ (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials of construction: concrete metal fiberglass polyethylene other
(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping.
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: D
Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or
out of box, etc.):
t9 !<, Ga�r1�c'tl��. �"i R�$� �7�.1,�.. Av.� �v, �enc�
_v �C'�i4K64 Cs£ l nr o!t C> --
PUMP CHAMBER: locate on sire plan)
Pumps in working order (yes or no)
Alarms in working order (yes or no)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
9'6f 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 337 Summer Street No. Andover, MA 01845
Owner's Name: Joseph Bissell
Date of Inspection: July 20, 2006
SOIL ABSORPTION SYS'T'EM (SAS): (locate on site Plan, excavation not required
If SAS not located explain why
TYPE
leaching pits number
leaching chambers, number
leaching galleries number
leaching trenches, number in length
✓ leaching fields, number, dimensions: ! Ic/CC D zC ` Xs'a
overflow cesspool, number:
innovative/altemative system Type/name of technology:
Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc)
c.go ups A-r� ezA4 4-L. - o, c �.JC
Ulm adn.JP--&J&- X16 C>i2 Un/"usk cjc��( &.c�
CESSPOOLSY�dj+. (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of Construction:
Indication of groundwater inflow (yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY:4�L--(locate on site plan)
Material of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
luof 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 337 Summer Street No. Andover, MA 01845
Owner's Name: Joseph Bissell
Date of Inspection: July 20, 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate
all wells within 100 feet. Locate where public water supply enters the building.
S V nn M it Z 5T2t ie -r
TJ15TA-jcc 5
I —T
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`17.0
Z - 1713
Z3 S
11'd 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 337 Summer Street No. Andover, MA 01845
Owner's Name: Joseph Bissell
Date of Inspection: July 20, 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water _feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record — If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health — explain:
Checked with local excavator, installers — (attach documentation)
_ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
r-> r; i3 Cc.�c.a. ��-JZ-�Oc= tn�sCsS t �y�•C�s
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APPRox
FxiST" �4
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: lo F f4x)1o1?A 9J,� L1, Phone r X5-3530
LOCATION: Assessor's Map Number Parcel
Subdivision
Street 32 cu m m m
************************Official
RECOMMENDA O S 0 /WNGENTS:
Conservation Adininigtrator
Comments
Town Planner
Comments
Food /Inspector -Health
Septic Inspector -Health
Comments 1A)6,e6c))j.b ?6oc
Lots)
St. Number
Use Only************************
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved AMU -
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
FAIL 1
N,C7,a n•,r_;n r«r. B0!A--P } OF, HEALTH
I14STALLATION CHECK LIST
D DATE DISAPPROVED DATE
i pp RE S:
OK
1. Distance To:
Wetlands
Drains
Well
2. Water Line Location
341 -**'No PVC Pipe
4. Septic Tank
es - Length & To Clean Out Covers
Cement Pipe to Tank - On Both Sides of Tank
5. Distribon Box
C r & Box - No Cracks
_r. 11 Lines Flowing Equal Amounts
/Dinsions
Flow
F. Ld or Trench
epth
Ends
ouble Washed Stone
7. Leach Pits
Dimensions
Stone Depth
Splash Pads
Tees
Cement Pipe to Pit - Both Sides
Clean Double !gashed Stone
"' No Gar -,age .Disposal
,�.r inal G:,,-ading Inspection
I rrac.a.ding Covered System
11. As - Built Submitted
Lot Location
Dimensions of System
Location with Regard to Pere Test
Elevations ,.--_
?.later Table �aa'`^^r
hXCAVATION OK
W
NOR jE ANDOVER .BOARD OF HEALTH
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
4P ROVID
PROVIDED DI MZ
/ . y
e -D . .
General Information
leg. 2.5 Fail OR The submitted plan must show as a minimum:
Reg. 6.1
Reg. 6.7
Reg. 6.0
Reg. 6.9
Reg. 6.1'
Reg. 6.1f
leg 3.7
a) the lot to be served (area dimensions, lot #, abutters)
b) -location and dimensions of system (including reserve area)
c� design calculations
d) -calculations showing required leaching area
4 existing and proposed contours
f) location and log of deep observation holes -distance to ties
g) location and results of percolation tests -distance to ties
h) location of any wet areas within 100' of the sewage disposal
system or disclaimer
I-) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
} location of any drainage easements within 100' of sewage
disposal system or disclaimer
F0 known sources of water supply within 200' of sewage disposal
system or disclaimer
1) location of any proposed well to serve the lot (1001 from leaching facili.
m)—location of water lines on property (10' from leaching facilities)
n) -maximum ground water elevation in area of sewage disposal system
location of benchmark
p) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
driveways
r garbage disposers
-s)—a profile of the system (elevations of basement, plumbers pipe
septic tank,. distribution box inlets and outlets, distribution
field piping and any other elevations)
) no PVC is to be used in construction
Capacities -
Water table
Tees
Depth of tees
Access
Pumping
150% of,flow
10' from cellar wall or inground swimming pool
25' from subsurface drains
MP s
a Approval
(b) Stand-by power
.t-
North(Andover Subsurface disposal system check-list-Page 2
_
Fai1,
CKDistributidn
Boxes
1
.
�)-S7bpe-greater--than -0.08----
Reg.10.4
IV(b)
Sump
eaching Pits
Leaching pits are preferred where the installation is possible
Reg. 11.2
(a) Calculations-of-leaching area (minimum 500 S.F.)
Reg.11.4
(b) Spacing
Reg.11.10
(c) Surface drainage 2%
Reg.11.11
(d) Cover material
each# Fields
Reg.15.1
-' (a) Greater than 20 minutes/inch
Reg.3 5.1
- b`}`Area (minimum 900 S.F. )
Reg.15.4
c Construction of field
Reg 15 8
Reg.3.
(e)-surface drainage 2%
e) 201 from cellar wall or inground sirimmi ng pool
•
t 31 Slope
a) Slope y/x = (to be shovm)
(b) y/x X 150 = (to be shown)
��
TO: NORTH ANDOVER, MASS 19
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
10.T 174 / ,4/21 e e North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19 .
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SOIL PROFILE & PERCOLATION TEST DATA
Town/ Ci No.&Street U Lot No.
Loc./Subdiv.// Plan Owner
Investigator a,- ,bQ s to Observer
0
'% SOIL PROFILES -DATE
S2
1' lev. ' Eley.3' Elev. 4'Elev.
o S 777 __5 77 o 0
4
3
2
5
`6
0
2
3
4
0
2
3
4
5
6
7
2
3
4
5
6
7
8
9
10 1 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests -Date
Pit Number
1
2 3 4 5
Start Saturation
Soak=Mins.
/
�S
Start Test -Time
Drop of 3" -Time
:2 2
ja: 33
Drop of 6" -Time
/G ; S
//--0-T
Mins.lst 3"Dro
Z -
Mins.2nd 3"Dro
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Notes & Sketches on Back
ZU-0
Frank C. Gelinas & Associates, North And.
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